Ethical Challenges Leading to Burnout

Sharon Clark discusses the relationship of the Hippocratic oath to the potential of physician burnout. Her paper on the Hippocratic Oath discusses the potential conflict between this common oath and today’s practice of medicine.

Clark Sharon A. The Impact of the Hippocratic Oath in 2018: The Conflict of the Ideal of the Physician, the Knowledgeable Humanitarian, Versus the Corporate Medical Allegiance to Financial Models Contributes to Burnout. Cureus. July 30, 2018;10(7):e3076. doi:10.7759/cureus.3076.

Much of the understanding of the Hippocratic Oath is based on myth and inaccurate, but the reality is almost all physicians agree to some oath at the end of their training. A key element is to put the patient’s needs first. As an example, the recently graduated physician agrees:

I swear to fulfill, to the best of my ability and judgment, this covenant:

I will respect the hard-won scientific gains of those physicians in whose steps I walk, and gladly share such knowledge as is mine with those who are to follow.
I will apply, for the benefit of the sick, all measures [that] are required, avoiding those twin traps of overtreatment and therapeutic nihilism.
I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon’s knife or the chemist’s drug.
I will not be ashamed to say “I know not,” nor will I fail to call in my colleagues when the skills of another are needed for a patient’s recovery.
I will respect the privacy of my patients, for their problems are not disclosed to me that the world may know. Most especially must I tread with care in matters of life and death. If it is given me to save a life, all thanks. But it may also be within my power to take a life; this awesome responsibility must be faced with great humbleness and awareness of my own frailty. Above all, I must not play at God.
I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person’s family and economic stability. My responsibility includes these related problems if I am to care adequately for the sick.
I will prevent disease whenever I can, for prevention is preferable to cure.
I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm.

If I do not violate this oath, may I enjoy life and art, respected while I live and remembered with affection thereafter. May I always act so as to preserve the finest traditions of my calling and may I long experience the joy of healing those who seek my help.

Much of the discussion of burnout discusses more behavioral explanations for burnout, that is those related to actions and situations. The article highlights a more ethical/philosophical basis for burnout due to the challenge of two ideals that cannot both be met. Specifically the need to put the patient’s needs first versus the need to address economic models associated with a movement toward more corporate based healthcare delivery.

She argues that the Oath does indeed place the physician at odds with the increasingly business-focused, financially constrained, health care system. Physicians that perceive that a patient’s needs are being subordinated to other requirements are placed in a conflict that potentially contributes to burnout. Unfortunately, the article does not present data demonstrating that such a conflict actually exists nor that the conflict causes burnout.

One interesting concept is the potential of considering the potential of agreeing to the Hippocratic Oath (or an equivalent) at the beginning of training rather than at the end similar to an agreement at matriculation to submit work as only one’s own. One might also argue that such an Oath should at least be considered even before applying to medical school or even earlier, say before considering becoming a pre-medical student. Such an early inspection of the future role of a physician would help the individual start to resolve conflict at an earlier stage, or at least to acknowledge and process two conflicting requirements.

It’s easy to write off such dissonance as it irrelevant. However, conflicting moral standards are certainly a potential cause of longer lasting stress that is difficult to resolve. This is a topic without a simple solution but one which will gain from reflection. One way of addressing this potential cause of burnout would be to present different scenarios that operationalize the conflict and to ask users to take an action. One can then can determine if this is potentially a problem and then consider ways that the conflict can be resolved.

We are looking into this issue and we will incorporate it into the simulation scenarios on the Clinical Encounters Platform that mirror the conflict between the Hippocratic oath (or its equivalent) and the practice of medicine. In the simulation, we can identify ethically challenging situations where the process of care limits the ability to act in the patient’s best interest due to reimbursement, time constraints, insurance requirements, hospital expectations, or other financial-based requirements. We can both assess if a conflict exists and offer means to resolve the conflict or simply to acknowledge it.